by dr jeb mcaviney bsc., mchiro., mpainmed., fcbp
TRANSCRIPT
By Dr Jeb McAvineyBSc., MChiro., MPainMed., FCBP
Adolescent Scoliosis in the Adult (ASA) &Degenerative De-Novo scoliosis (DDS)
Adult ScoliosisASA is pre-existing AIS but in
adulthood
DDS is a new development
of scoliosis in adulthood.
The primary concern in most
adult cases is Pain
Progression and Aesthetics
are also considerations
ASA 1• Usually smaller flexible curves in
younger adults 18-30 years old
• Posture and Cosmetic issues are
the main problem.
• Pain can be an issue particularly in
unbalanced curves
• Potential reducibility in both
abnormal posture and Cobb.
ASA 2• Usually larger more rigid curves in
middle aged adults 30-40• Pain and posture equally issues.• Pain can be an issue even in
balanced curves.• Often start to see early
degenerative changes• Intervention in ASA 2 could
potentially to stop progression to ASA 3
ASA 3• Usually large, rigid curves in older
adults 40+• Pain is the primary issue.• Moderate to severe degenerative
changes present.• Most commonly lumbar curves.• No previous history of scoliosis
could indicate Degenerative De Novo Scoliosis DDS.
Degenerative De-Novo Scoliosis (DDS)• New curve in adult developed as a
result of degenerative instability.
• Usually lumbar curve, unbalanced.
• Large, rigid curves in older adults 50+
• Pain is the primary issue.
• Moderate to severe degenerative
changes present.
Prevalence of Adult Scoliosis in Back Pain Perennou et al; 671 LBP patients:
7.5% had evidence of scoliosis.
Prevalence of scoliosis increased with age;
2% before 45 years (most likely ASA)
15% after 60 years (probably DDS)
Prevalence of Adult Scoliosis in Back Pain Robin et al;554 LBP patients
Aged 50 to 84 30% scoliosis >10°
At 5 year follow up 40% scoliosis >10°Additional 10%
“a significant number of older people have an adult scoliosis” and its prevalence and progression is directly related to advancing
age”
“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
Schwab’s research identifies these radiographic parameters as important:
•Level of regional balance.
•Instability
•Pathologic mechanical loads of the spinal elements
“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
He identifies these correlations with pain:
•Lateral vertebral olisthy, (side slip)
•L3 and L4 endplate obliquity angles,
•Decrease in lumbar lordosis,
•Increased thoraco-lumbar kyphosis
“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002,
• The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS.
• Early intervention in a middle-aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly.
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
298 patients
The purpose of the study was to correlate radiographic measures of deformity with patient-based quality of life and health status assessments in adult scoliosis.
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
The most significant findings were:Positive (anterior) Sagittal Balance
Greater pain Diminished physical function Poorer self image Poorer social function
Coronal shift > 4 cm Poorer function Greater pain
Compared to patients with a coronal shift < 4 cm.
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
Key PointsPositive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity.Thoracolumbar and lumbar curves have worse outcomes than thoracic curves.Significant coronal imbalance was associated with pain and dysfunction.
“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003
Progression of Adult Curves• Progression in ASA 1&2 is generally not a major concern unless the
curve is already very large >60 deg
• Danielson and Nachemson in Spine 2003 found that 36% of adolescents with scoliosis had progressed by more than 10° after 22 years.
• ASA 3 and DDS can become moderate to severely progressive due to degenerative instability and or hormonal influence.
• The most progressive DDS cases often have osteoporosis as a co-morbidity
Progression of Adult Curves
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007
Two main types were identified:
1) Type A • Adolescent scoliosis• Progresses after skeletal
maturity
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007
Two main types were identified:
2) Type B • Progresses late in adulthood:• Pre-existing stable adult scoliosis
with late progression• De novo late-onset scoliosis.
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007
Progression was measured at a liner rate specific to each curve.
“We did not find any correlation between the initial Cobb angle and slope of progression in the
overall population.”
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007
Role menopause plays
In 8 women with type A scoliosis with a long progression comprising menopause, no change of slope was observed at menopause.
Patients with type B scoliosis were all women and exclusively presented a lumbar or thoracolumbar single curve.
In type B, 11 out of 20 of these patients progressed at the time of menopause.
Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007Summary
The progression of adult scoliosis is linear. It can be used to establish an individual prognosis.
Two main types exist: Adolescent scoliosis, which continues to progress (type A)
ASA 1&2Late onset scoliosis, either pre-existing stable adolescent
scoliosis or de novo (type B). ASA3 & DDSMenopause constitutes a period of deterioration for type B.
Progression of Adult CurvesType BM
Menopause
DDS Development
50 yr old woman minor LBP 5 years latter developed DDS
Adult Scoliosis TreatmentIncreased Life Expectancy vs. Long term Quality of LifeIncreased Life Expectancy vs. Long term Quality of Life• Degenerative pathologic conditions in aging persons are increasingly of
concern in regards to long term quality of life and independence
• The focus of medical treatment in Adult cases is usually on regional degenerative pathologic conditions such as stenosis, spondylolisthesis, disc degeneration etc. rather than the deformity itself!
“Although the common degenerative conditions of the spine are frequently treated as focal pathologic states, it appears intuitive that deformity of the spinal column, by altering the mechanical loading conditions, can accelerate the degenerative cascade.” Schwab et al, Spine 2002
Adult Scoliosis TreatmentRigid vs. Dynamic Orthosis for Treatment
Rigid DynamicMuscle Atrophy in unstable system Limitation of movementSelf image issues Comfort issuesUseful in Neuro-degenerative cases
Muscle rehabilitation and stabilizationAllows movementNot visible under clothingRelatively comfortableSuitable for long term useNot suitable for Neuro-degenerative
cases
Goal is improvements in Sagittal and Coronal balance not a forced reduction in Cobb angle
Corrective Movement & Spinal Loading
CLASSIFICATION CORRECTIVEMOVEMENT
BRACEIN PLACE
LEFT LUMBAR
SpineCor Adult Treatment
SpineCor and Sagittal BalanceCorrective movement for Anterior Sagittal Balance
First have the patient stabilise their lordosis by the contraction of abdominal and gluteus muscles.
Second translate the base of the thorax slightly forwards and upwards.
SpineCor Adult Brace
Examples of Adult treatment Patient A 26 year old female, Painful adolescent idiopathic
scoliosis as an adult (ASA1). Pain 7/10. 8 to 12 hours for 3 months Gradual relief of pain to 2/10. 32 deg right thoracic scoliosis. Improvement of 8 degrees to 24
deg. Relief of 1-2/10 and spinal
correction have been maintained for over 2 years .
Courtesy of Dr Tom Pappas
Examples of Adult treatment Patient B 47 year old female Degenerative De-Novo Adult
Scoliosis. (DDS) Pain 7/10. Immediate relief of pain to 3/10. A 40 deg degenerative lumbar
scoliosis. Improvement of 7 degrees to 33
deg. Pain relief of 0-3/10 maintained
for over 2 years Note the improved left lateral
shift showing “spinal off loading”. Courtesy of Dr Tom Pappas
Thank you Thank you